Title: General Care After Stroke, Including Stroke Units and Prevention and Treatment of Complications of Stroke
1General Care After Stroke, Including Stroke
Units and Prevention and Treatment of
Complications of Stroke
2Reasons for Admission
- Serious illness
- Potentially life-threatening disease
- Risk for medical or neurological complications
- Neurological deterioration
- Observation, evaluation and treatment
3Organization of Stroke Care
- Acute Stroke Units
- Concentrate admissions to a specialized facility
with skilled care and monitoring. - Shorten hospitalizations and reduce death and
disability. - Reduce complications and promote rehabilitation.
4Organization of Stroke Care
- Stroke Teams
- Coordinated teams of health care professionals to
coordinate efficient and effective care for
stroke patients. - Stroke Teams play a part in the hyperacute, the
acute and the rehabilitation phases of stroke
care. - Involve the multidisciplinary team.
5Stroke Centers
- Primary Stroke Centers
- Use the cardiac/trauma model of delivering care.
- Major elements patient care and support
services. - Define institutions where appropriate care can be
given.
6Goals of Treatment After Admission
- Continue care started in emergency department.
- Observe for and prevent or control neurological
and medical complications. - Start rehabilitation and discharge planning.
- Evaluate for cause of stroke and start therapies
to prevent recurrent stroke.
7Neurological Complications
- Progression of thrombosis
- Recurrent embolism
- Brain edema
- Hydrocephalus
- Increased intracranial pressure
- Hemorrhagic transformation
- Seizures
8Medical Complications
- Myocardial infarction Pneumonia
- Congestive heart failure Airway obstruction
- Cardiac arrhythmias Hypertension
- Deep vein thrombosis Bladder infections
- Pulmonary embolus Depression
- Gastrointestinal bleeding Electrolyte
disturbance -
9After Admission
- Initially treated with bed rest mobilization
begins as soon as the patients condition is
stable - Pulse oximetry first 24-48 hours
- Cardiac monitoring first 24 hours
10After Admission
- Frequent assessments of vital signs and
neurological status by nursing staff. - Protection of airway, especially if depressed
consciousness or signs of brain stem dysfunction. - Supplemental oxygen if patient is hypoxic.
- Assessment for cause of hypoxia.
11Heart Disease and Stroke
- Heart disease often is the cause of stroke.
- Most patients with stroke have heart disease.
- Stroke, especially intracranial hemorrhage, can
cause myocardial ischemia or cardiac arrhythmias. - Many persons will have cardiac arrhythmias or
electrocardiographic abnormalities after stroke.
12Heart Disease and Stroke
- Sinus bradycardia Sinoatrial arrhythmia
- Ventricular tachycardia Atrial fibrillation
- Ventricular fibrillation PVC
- Idioventricular rhythms PSVT
- Torsades de pointes AV block
13ECG Changes and Stroke
- ST-T segment elevation/depression
- Pathological Q waves
- Negative T waves
- Abnormal U waves
- QT prolongation
14Hypertension in Stroke
- Arterial hypertension is common among persons
with stroke - risk factor for stroke
- consequence of stroke
- Usually declines spontaneously
- Secondary to pain, vomiting, stress, anxiety
- Secondary to increased intracranial pressure
15Treatment of Arterial Hypertension
- Oral agents preferred
- Continue or re-institute antihypertensive
medications - Goal of lowering pressure by 15 during first 24
hours - If parenteral medications are used, prefer
short-acting drugs
16Initial Management of Acute Stroke
- Treat fever and search for the cause of fever
suspect pulmonary or urinary tract infections - Maintain hydration with intravenous fluids
- Treat hyperglycemia and hypoglycemia
- Assess swallowing before starting oral feedings
- If necessary, consider enteral feedings
17Mobilization After Stroke
- Early mobilization
- positive for morale
- expedites rehabilitation
- lessens risk of pulmonary, skin, musculoskeletal
complications - Watch for hypotension or neurological worsening
- Protect against falls
18Prevention of DVT and Pulmonary Embolism
- Mobilization
- Heparin
- LMW heparins/heparinoids
- Oral anticoagulants
- Aspirin
- Alternating pressure stockings
19Brain Edema and Increased Intracranial Pressure
- Peaks within one week of stroke
- Earlier with hemorrhagic stroke
- A leading cause of death
- Seen with large multi-lobar strokes
- Can be secondary to hydrocephalus or mass effect
of a hematoma
20Brain Edema and Increased Intracranial Pressure
- Common cause of neurological worsening
- progression of stroke
- secondary brain ischemia
- herniation syndromes
- Hallmark is depression of consciousness
- Vital signs unstable and arterial hypertension
21Management of Brain Edema and Increased
Intracranial Pressure
- Restrict fluids moderately
- Avoid hypo-osmolar fluids
- Control fever, hypoxia, hypercarbia
- Elevate head of bed by 30
- Monitor intracranial pressure
22Trial of Dexamethasone for Supratentorial
Intracerebral Hemorrhage
- Dexamethasone Placebo
- n46 n47
- Good Recovery 8 5
- Poor Survivor 17 21
- Dead 21 21
- Infectious Complications 13 6
- Pougvarin, et al. New England Journal of
Medicine 19873161229-1233..
23Intracranial Pressure
- Hyperventilation to a pCO2 of approximately 28-30
mm Hg - Corticosteroids are not recommended
- Mannitol, 0.25-1 g/kg intravenously given every 6
h maximum osmolarity 310 - Furosemide 40 mg intravenously
24Surgical Management of Brain Edema and ICP
- Drainage of CSF fluid
- Evacuation of hematoma
- Resection of infarcted tissue
- Hemicraniectomy
25Evaluation for Cause of Stroke
- Magnetic resonance imaging of brain
- Magnetic resonance angiography
- Spiral CT imaging
- Carotid duplex
- Transcranial Doppler
- Transthoracic echocardiography
- Transesophageal echocardiography
26Prevention of Recurrent Stroke Cardioembolic
Stroke
- Oral anticoagulants
- prosthetic valves INR 2.5-3.5
- other causes INR 2.0-3.0
- Stroke despite adequate anticoagulation
- add aspirin
- add dipyridamole
- Contraindication for anticoagulation
- Aspirin
27Prevention of Recurrent Stroke
- Carotid endarterectomy if ipsilateral high-grade
stenosis, acceptable risk, and skilled surgeon - Antiplatelet aggregating drugs
- Aspirin
- Ticlopidine
- Aspirin and dipyridamole
28Rehabilitation
- Critical part of care after stroke
- Begin as soon as patient is stable and while the
patient is still in an acute care bed - Tailor to individual patients needs
- Progress in a step-wise progression
- Maximize patients independence
29Decisions About Rehabilitation Influence
Discharge Planning
- In-patient rehabilitation unit
- attached to acute hospital
- free-standing hospital
- Outpatient care
- Home care
- Skilled nursing facility
30Discharge Planning Considerations
- Cognitive and functional status
- Family and caregivers support
- Financial resources
- Patient and family education
- Follow-up medical care, rehabilitation
- Identify safe place of residence
- Community support or resources